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Pediatr Crit Care Med. 2019 Apr 3. doi: 10.1097/PCC.0000000000001923. [Epub ahead of print]

Adverse Tracheal Intubation-Associated Events in Pediatric Patients at Nonspecialist Centers: A Multicenter Prospective Observational Study.

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Children's Acute Transport Service, Boswell Street, Great Ormond Street Hospital, London, United Kingdom.
Paediatric Intensive Care Unit, Great Ormond Street Hospital, Great Ormond Street, London, United Kingdom.
Paediatric Intensive Care Unit, St. Mary's Hospital, Praed Street, London, United Kingdom.
Department of Anaesthesia, Royal London Hospital, Whitechapel Road, London, United Kingdom.
Paediatric Intensive Care Unit, Evelina London Children's Hospital, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom.
Department of Anaesthesia, Great Ormond Street Hospital, Great Ormond Street, London, United Kingdom.



In tertiary care PICUs, adverse tracheal intubation-associated events occur frequently (20%; severe tracheal intubation-associated events in 3-6.5%). However, pediatric patients often present to nonspecialist centers and require intubation by local teams. The rate of tracheal intubation-associated events is not well studied in this setting. We hypothesized that the rate of tracheal intubation-associated events would be higher in nonspecialist centers.


Prospective observational study.


We conducted a multicenter study covering 47 local hospitals in the North Thames and East Anglia region of the United Kingdom.


All intubated children transported by the Children's Acute Transport Service from June 2016 to May 2018.




Data were available in 1,051 of 1,237 eligible patients (85%). The overall rate of tracheal intubation-associated events was 22.7%, with severe tracheal intubation-associated events occurring in 13.8%. Younger, small-for-age patients and those with difficult airways had a higher rate of complications. Children with comorbidities and difficult airways were found to have increased severe tracheal intubation-associated events. The most common tracheal intubation-associated events were endobronchial intubation (6.2%), hypotension (5.4%), and bradycardia (4.2%). In multivariate analysis, independent predictors of tracheal intubation-associated events were number of intubation attempts (odds ratio for > 4 attempts compared with a single attempt 19.1; 95% CI, 5.9-61.4) and the specialty of the intubator (emergency medicine compared with anesthesiologists odds ratio 6.9; 95% CI, 1.1-41.4).


Tracheal intubation-associated events are common in critically ill pediatric patients who present to nonspecialist centers. The rate of severe tracheal intubation-associated events is much higher in these centers as compared with the PICU setting. There should be a greater focus on improving the safety of intubations occurring in nonspecialist centers.

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